Provider Demographics
NPI:1326363698
Name:OSTERDAHL, BONNIE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:
Last Name:OSTERDAHL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 161
Mailing Address - Street 2:
Mailing Address - City:OTISVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10963-0161
Mailing Address - Country:US
Mailing Address - Phone:845-343-6686
Mailing Address - Fax:
Practice Address - Street 1:45 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-1912
Practice Address - Country:US
Practice Address - Phone:845-343-6686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113375-1273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit